• Rutger T Theijse, Thomas F Stoop, Tessa E Hendriks, J Annelie Suurmeijer, F Jasmijn Smits, Bert A Bonsing, Daan J Lips, Eric Manusama, Erwin van der Harst, Gijs A Patijn, Jan H Wijsman, Mark Meerdink, Marcel den Dulk, Ronald van Dam, StommelMartijn W JMWJDepartment of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands., Kees van Laarhoven, Roeland F de Wilde, Sebastiaan Festen, Werner A Draaisma, Koop Bosscha, van EijckCasper H JCHJDepartment of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands., Olivier R Busch, I Quintus Molenaar, Bas Groot Koerkamp, Hjalmar C van Santvoort, Marc G Besselink, and Dutch Pancreatic Cancer Group.
• Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
• Ann. Surg. 2023 Dec 11.

ObjectiveTo assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D.Summary Background DataMorbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking.MethodsNationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed.ResultsOverall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%).ConclusionThis nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

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